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Presenters/Topics:

• Cathleen Marrow, M.D., Dartmouth, Geisel School of Medicine: Chronic Disease and Shared Decisionmaking: Practical Applications
• Sheri Reder, Ph.D., M.S.P.H., VA Puget Sound Health Care System: Shared Decisionmaking for Aging Veterans: It's a Team Effort

Moderator:

• Arlene Bierman, M.D., M.S., Director of Center for Evidence and Practice Improvement, AHRQ

1. When would you use motivational interviewing as opposed to shared decisionmaking?­ How do you decide when to use one or the other approach with a patient?

   Cathleen Morrow: Motivational interviewing and shared decisionmaking are two different communication skills that clinicians often dance between depending on the clinical circumstances. Motivational interviewing is a specific skill for clinical situations where there are not a lot of options and the evidence is overwhelming toward a given choice, and our goal is to help motivate the patient toward that choice. A classic motivational interviewing topic is quitting tobacco use.

   For shared decisionmaking, we're using communication to explore options and to understand patient values and preferences in order to help them decide what is the best choice for them—for example, if I’m trying to figure out how to get a patient to decide whether to use a fit card testing annually versus getting a colonoscopy. Choosing between multiple options depends on values and preferences, insurance, resources, time from work, and so on.

2. When you do decide to use shared decisionmaking, how do you decide what modality to use (paper versus a conversation versus an electronic tool)? And is there evidence on the relative effectiveness of different types of shared decisionmaking approaches and tools?-

   Morrow: Patients differ widely in their uptake of decision aids and the modality you use. For many geriatric patients, using electronic tools is simply not helpful, and the conversation itself is most important.

   For younger people, who live on the Web and dash between one electronic device and another, using electronic tools can be extremely useful. However, I don’t think anything replaces a conversation, particularly when there is a medical decision that needs to be made. Plus, knowing your patient well can help you decide what modality to use.

3. Are the VA decisionmaking aids in an audio form for visually-impaired people?

   Sheri Reder: They are not available with audio at this time. The tools can be downloaded from the Web site, so they’re easily available to people in that way. But they are not available with audio.

4. The main take-home point that I am hearing is SDM is a language or communication technique, while CMS is making SDM about tools—not communication.  Am I hearing you correctly?

   Morrow: Exactly right. SDM is an important communication tool. When CMS talks about tools, I think they are referring to decision aides, but I interpret CMS broadly as both aspects of good SDM. In documentation I often use the terminology that “an SDM approach is used in consideration of this decision.”

5. Please explain asynchronous discussions a little more and give an example.

   Morrow: We use the term “asynchronous care” to refer to the care that happens outside of the individual office visit. This includes electronic messaging, phone calls management, and follow-up visits done by some methodology other than direct in-person visits.

   Reder: SDM is a process in which the older person/patient, their family/caregiver, their provider(s), their social worker, and other team members all contribute to a discussion about the older person's goals, priorities, and needs, as well as their options for achieving those goals, priorities, and needs. These discussions do not need to occur as a single team meeting, but rather may take place as multiple one-on-one discussions that eventually result in a decision by the older person about how to proceed.

6. My primary care now uses more technical language, I believe due to the terminology of EMR.  Have you considered using more plain language in trainings geared toward health professionals so that it facilitates plain language use with clients/patients?

   Morrow: Shared decisionmaking for providers should include the use of plain language. Avoiding the use of technical jargon is very important in shared decisionmaking.

7. Have the tools and the implementation process you described for the VA shared decisionmaking program been tested in randomized trials or otherwise rigorously evaluated and reported in the peer-reviewed literature?

   Reder: No, the implementation process has not been tested in randomized trials. The SDM for Aging Veterans process and materials were developed based on quality improvement interviews with older veterans, caregivers, and providers. They have now been implemented in multiple settings across the country, and quality improvement feedback has been gathered and assessed via interviews with a sample of veteran, caregiver, and provider participants. Based on this feedback, revisions have been made.

8. What is the anticipated time to roll out SDM to all VA facilities? ­Is there an expectation to expand the VA SDM site implementation to more states in the stroke belt with large elderly populations?

   Reder: I would love to have a comprehensive rollout, but that isn’t really how VA operates. While VA is a centralized organization, there is great diversity among the various VAs across the country, and SDM is being implemented separately at each medical center and program. So we have continued SDM’s spread by working with Geriatrics and Extended Care, Social Work, the Office of Rural Health, and other offices that strongly support using it with aging veterans. Plus, we have a plan to make sure that all the home-based primary care programs receive the shared decisionmaking training, are aware of the program, and implement it.

9. Are there any best practices for when the vet lives in another state and family members are scattered in various states?

   Reder: it’s very common for older people, including older veterans, to be more isolated and have families in other locations. We go to great effort to contact those people. That's part of the shared decisionmaking process. That has been a priority at VA for some time to make sure that family caregivers are really involved in the process. And I would say during the past decade that has only increased in importance.

10. Can you expand a bit on SDM’s clinician time requirements? Although studies suggest it typically adds only a few minutes to the visit, it still is such a (perceived) barrier.

    Morrow: You are absolutely right. The idea that it takes too much time is pervasive, and we have a long way to go to help providers understand that, in the long run, it saves time. Well-educated, well-informed patients who have used some decision aids (such as a video or fact sheet) ahead of time make the conversation much more efficient. They tend to come pre-educated with some questions already in place, so you don't have to start the conversation at the very beginning. And as we become more proficient in our use of these skills, we also become more effective at helping patients reach decisions and knowing what is most useful and helpful to them.

    Also, this is a team sport. Physicians and other providers can't do this on their own. In my facility, often a lot of the advance work is done by a health coach, a care manager, our medical assistants, or other nursing support services, so the conversation has already been primed. This helps me have an efficient shared decisionmaking conversation when the time comes.

    Reder: Feedback from our quality improvement interviews with providers indicates that SDM does not add a significant amount of time to the visits—especially when it is implemented by the full team, so that the social worker facilitates most of the discussion. In addition, providers find that use of SDM materials decreases certain aspects of the visit, because the patient and family are better prepared for the visit and more familiar with the options available to address their goals, priorities, and needs (e.g., respite care).

11. The statin study found increased calories, etc. Did they follow up with participants to find out why this might have happened?­

    Morrow: The study was not designed to answer why; it simply observed the fact that patients on statins ate more calories, had higher BMIs, and gained more weight than the non-statin folks. The authors theorize that statins can create a false sense of security for patients, leading to more carelessness about diet and exercise. My thought is that it may do the same for providers. That is, we may think we have solved the problem when we prescribe statins, so we may emphasize diet and exercise less.

12. Has anyone used SDM with adolescents? If so, how does it differ from working with adults?

    Morrow: Yes, although I have not seen any studies. The classic SDM adolescent case is contraceptive choice—a perfect example of preference-sensitive care. Adolescents really respond to the SDM approach, in my experience. After all, they are working on autonomy and thinking a lot about choice as they grow through this developmental stage.

13. Sometimes staff does get fatigued in this process and fall back on "well, this is the patient's choice," even if the choice is not evidence based or well informed. Is this abandonment?

    Morrow: No, I would not call this abandonment. I would call it being realistic, in some cases. But my argument here with providers who fall back on the "this patient is never going to change" attitude is that we NEVER know when a patient will change. When the life circumstances of a given patient provoke that teachable moment, our job is to seize it when it comes! So I think it is very important to never give up hope and to communicate to patients who have made it clear that they are not going to do anything different that you respect their decision, but that you will be bringing it up with them in the future! I often say: "I hear you. I understand this is how you feel at this time. I promise you I will be bringing this up with you at every visit in the future, because it is so important to your health."

    Reder: No, this is not abandonment. There may well be reasons for the patient's choice that are outside the boundaries of what is best from a medial perspective. Staff needs to do a good job explaining the medical and functional implications, and then accept the patient's choice.

14. What, in particular, do you see the MA doing as a player on the SDM team?

    Morrow: The health coaches and the care managers are all trained in a shared decisionmaking approach. If a patient is given a new diagnosis, say of diabetes, I would be very quick to offer the services of a health coach. A great deal of the early work is done by the health coach, so in my regularly-scheduled follow-up, I'll be in a better position to tackle the more complicated medical challenges or questions.

    We've been experimenting a little bit with giving medical assistants some core skills. They are collecting information from the patient and updating the patient's chart with medical, family, and social history changes. So simply giving them some additional questions to ask about preferences and values allows medical assistants to have a very useful conversation with a patient.

    When you use shared decisionmaking, it’s important to document it in the notes in order to keep the whole team informed. When we refer a patient to a diabetes educator or health coach, we talk or exchange an email with them about the purpose and goals of the referral.

    Reder: It's important to do an SDM orientation for the whole team or service line. This orientation gives everybody on the team a common understanding of shared decisionmaking, what the process is, and what their role will be. It also gives them a chance to practice using SDM.

    VA medical centers vary greatly in size. They can be residential or home-based. And providers see patients for varying amounts of time. So roles vary greatly. At some VA centers, nurses may start the SDM process by making sure the patient gets the packet of materials and is familiar with it. They may also talk with the patient about their condition and treatment options. At other centers, the administrative person may hand out the packet. Social workers and physicians may play a key role in SDM too.

15. Can you share the latest evidence about whether clinician training in SDM (such as the training developed by Nan Cochran at Dartmouth) improves the quality of SDM and SDM outcomes?

    Morrow: This is a very difficult outcome to measure. We have been teaching our medical students for 5 years in these techniques, and Nan has done extensive teaching of providers around the country. There are several early instruments that are being worked on in the Preference Laboratory at the Dartmouth Institute trying to address this question. The CollaboRATE study has been collecting a lot of data about our providers in PC here at Dartmouth based on how patients rate their providers' effectiveness at informing them and including them in the decisionmaking process. These have not yet been published. With the medical students we have rated students' effectiveness after the training, but of course we don't know how well they do over time in practice. Much more research is needed in this area.

16. Has SDM been used to help patients choose a specific site for living (i.e., assisted living or nursing home)? Are SDM tools available to help patients to select specific providers based on preferences? Or is SDM best for determining the level of care needed?

    Morrow: I do not know of any studies about its specific use for this issue, but the approach clearly would be very helpful in this area. I think it is a really interesting idea to use SDM to help patients find appropriate providers. I guess in some ways the patient representatives who take calls and ask individuals what they are looking for in doctors do that (informally at best!).

    Reder: Yes, SDM is definitely used to help patients select their living site. That is one of the core purposes of the SDM for Aging Veterans. We have not used it to select specific providers, and I don't know if it has been used in that way.

17. Doesn't the eligibility of veterans vary widely? Would this change the options available to them?

    Reder: Yes, there are differences in eligibility for services among veterans. Information about eligibility is one of the topics that is covered on the Geriatrics and Extended Care website and in the SDM process. It is also true that most of the long-term services and supports are part of the VA Basic Medical Package and available to all enrolled veterans. Finally, the SDM process is based on providing comprehensive information about the full range of long-term services and supports to all patients, as we providers and social workers never know when a patient will decide to access a service that is not covered by VA.

18. With the current findings that most suicides are in the vet population 55 and older, is there any way to determine how the practices in chronic disease management and engagement of vets and caregivers can stop it?

    Reder: VA has an extensive Mental Health and PTSD program. However, those are not my areas of expertise.

19. The signature wound in the wars in Afghanistan and Iraq is traumatic brain injury. Have you developed a best practice focus on engagement due to the cognitive challenges post injury?

    Reder: VA has an extensive TBI program. However, that is not my area of expertise.